Çocuklarda dirsek çıkığına eşlik eden medial epikondil kırıklarının tedavisi
Amaç: Kliniğimizde, dirsek çıkığına eşlik eden medial epikondil kırığı nedeniyle tedavi edilen çocuk hastaların klinik ve radyografik sonuçları değerlendirildi. Çalışma planı: Bu çalışmaya, dirsek çıkığına eşlik eden medial epikondil kırığı olan 10 çocuk hasta (9 erkek, 1 kız; ort. yaş 12; dağılım 1.5-15) alındı. Üç hastada posteromedial, yedi hastada posterolateral çıkık vardı. Üç olguya konservatif, dört olguya erken cerrahi (7. günden önce), üç olguya geç cerrahi (7. günden sonra) tedavi uygulandı. Cerrahi tedavi uygulanan hastaların üçünde eklem içi fragman, dördünde ise instabilite vardı. İnstabilite olan olguların hepsinde medial epikondilde 5 mm’nin üzerinde deplasman vardı. Cerrahi tedavi uygulanan hastalarda posteromedial insizyon kullanıldı ve ulnar sinir eksplorasyonu yapıldı. Klinik sonuçlar Mayo dirsek performans skoru ile de- ğerlendirildi, 75 puan ve üstü yeterli sonuç olarak kabul edildi. Ortalama izlem süresi 28 ay (dağılım 3-103 ay) idi. Sonuçlar: Hastaların tümünde medial epikondil kırığı 4-6 haftada kaynadı. Mayo dirsek skoruna göre olguların hepsinde 75 puan ve üstü (ortalama 93.5) sonuç alındı. Mayo dirsek skoru yedinci günden sonra ameliyat edilen olguların ikisinde 80, birinde 75, diğer tüm olgularda 100 puan idi. Konservatif ve erken cerrahi tedavi uygulanan tüm hastalarda dirsek hareket açıklığı tamdı. Geç cerrahi tedavi uygulanan hastaların birinde 5° ekstansiyon, birinde ise 10° şeksiyon kaybı görüldü. İnstabilite nedeniyle ameliyat edilen dört olgunun son kontrollerinde instabilite saptanmadı. Çıkarımlar: Medial epikondilin eklem içinde olduğu ve 5 mm üzerinde deplasmanı olan olgularda cerrahi, 5 mm ve altında deplasmanı olan olgularda konservatif tedavinin en iyi seçenek olduğunu düşünüyoruz.
Treatment of medial epicondyle fractures accompanying elbow dislocations in children
Objectives: We evaluated the clinical and radiographic results of treatment for medial epicondyle fractures accompanying elbow dislocations in children. Methods: The study included 10 children (9 boys, 1 girl; mean age 12 years; range 1.5 to 15 years) with medial epicondyle fractures accompanying elbow dislocations. Three patients had posteromedial and seven patients had posterolateral dislocations. Three patients were treated conservatively, while four patients and three patients underwent early and late surgical treatment before or after the seventh day of injury, respectively. Surgery was indicated due to entrapment of the medial epicondyle fragments in three patients, and to instability in four patients with more than 5 mm of displacement. At surgery, a posteromedial incision was used and ulnar nerve exploration was performed. The results were evaluated using the Mayo elbow performance score. The mean follow-up period was 28 months (range 3 to 103 months). Results: Union of the medial epicondyle fractures was achieved between four to six weeks in all the patients. The mean Mayo elbow performance score was 93.5. Late surgery was associated with a score of 80 in two patients and 75 in one patient, the remaining patients had an excellent result (100 points). Full range of elbow motion was achieved in all the patients treated conservatively and with early surgery; however, following late surgery, two patients had extension and flexion losses of 5° and 10°, respectively. None of the patients had instability postoperatively. Conclusion: Patients with entrapment of the medial epicondylar fragment in the joint and with a displacement of more than 5 mm should undergo surgery, while those with a displacement of 5 mm or less can be treated conservatively.
___
- 1. An KN, Chao EY. Functional evaluation of the elbow. In: Morrey BF, editor. The elbow and its disorders. 2nd ed. Philadelphia: W. B. Saunders; 1993. p. 85-97.
- 2. Herring JA. Upper extremity injuries. In: Tachdjian’s pediatric orthopaedics. Vol. 3, 3rd ed. Philadelphia: W. B. Saunders;2002. p. 2191-4.
- 3. Durakbasa O, Kucukyazici O, Tuygun H, Okan N, Gorgec M. Surgical treatment of elbow fracture-dislocations seen in children and adolescents. [Article in Turkish] Acta Orthop Traumatol Turc 2003;37:304-8.
- 4. Papandrea R, Waters PM. Posttraumatic reconstruction of the elbow in the pediatric patient. Clin Orthop Relat Res 2000;(370):115-26.
- 5. Pimpalnerkar AL, Balasubramaniam G, Young SK, Read L. Type four fracture of the medial epicondyle: a true indication for surgical intervention. Injury 1998;29:751-6.
- 6. Hines RF, Herndon WA, Evans JP. Operative treatment of medial epicondyle fractures in children. Clin Orthop Relat Res 1987;(223):170-4.
- 7. Fowles JV, Slimane N, Kassab MT. Elbow dislocation with avulsion of the medial humeral epicondyle. J Bone Joint Surg [Br] 1990;72:102-4.
- 8. Kobayashi Y, Oka Y, Ikeda M, Munesada S. Avulsion fracture of the medial and lateral epicondyles of the humerus. J Shoulder Elbow Surg 2000;9:59-64.
- 9. Fowles JV, Kassab MT, Moula T. Untreated intra-articular entrapment of the medial humeral epicondyle. J Bone Joint Surg [Br] 1984;66:562-5.
- 10. Farsetti P, Potenza V, Caterini R, Ippolito E. Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg [Am] 2001;83:1299-305.
- 11. Royle SG. Posterior dislocation of the elbow. Clin Orthop Relat Res 1991;(269):201-4.
- 12. Michelsson JE, Rauschning W. Pathogenesis of experimental heterotopic bone formation following temporary forcible exercising of immobilized limbs. Clin Orthop Relat Res 1983;(176):265-72.